Multiple unhealthy risk factors: why they matter and how practice is changing

Seven in ten adults in England in 2008 had two or more risk factors of poor diet, physical inactivity, excessive alcohol consumption and smoking. Previously, The King’s Fund has looked at the prevalence of multiple unhealthy behaviours, and now we are revisiting this area by looking at how some services are developing a response to the reality that most people experience risk factors in combination. Developing approaches to tackling multiple risk factors is crucial for three reasons.

First, these risk factors – poor diet, physical inactivity, excessive alcohol consumption and smoking – are linked to ill health and premature death. A study in 2008 forcefully highlighted the problem when it found that, after following up its cohort for 11 years, an individual with all four risk factors had a four-fold risk of dying compared with someone who ate well and was active, and didn’t smoke or drink to excess. What’s more, research shows that having multiple risk factors contributes to greater ill health.

Second, there is an inequalities aspect to multiple risk factors, where those in lower socio-demographic groups are more at risk. For example, by 2008 the odds of those with no qualifications having all four risk factors compared to those with the most education had climbed to five-fold (compared to three-fold in 2003). Multiple unhealthy risk factors are therefore an inequalities problem. Research has also found a link between unhealthy risk factors and working night-shifts, giving robust form to an intuitive finding: working life can have an impact on living a healthy life.

And finally, despite clear evidence of the prevalence and harm of combinations of risk factors, most of our tools for supporting behaviour change tend to be designed for tackling single risk factors. We have ‘stop smoking’ services, cooking classes and physical activity promotion, but we have very little policy that looks at the links between these. Now, however, services are evolving that take a more holistic view of the individual. In our report, we describe some local authority and NHS health and wellbeing services that are thinking about how the problem of multiple unhealthy risk factors can be addressed head on.

Some of these services have established a single point of access across behaviour services, while others provide one-to-one support with behaviour advisers across a range of behaviours, not just the one the client comes in the door with. Services often target deprived neighbourhoods, in the knowledge there will be more people in need of multiple risk factor support there. They also often work to a greater or lesser degree with the NHS (and some operate within the NHS), attempting to identify individuals with multiple risk factors. Services are innovating in response to emerging evidence about how best to target and support individuals with multiple unhealthy risk factors.

Designing a multiple unhealthy risk factors service is no walk in the park. The evidence about the problem is much more developed than evidence about the solution. Looking at multiple risk factor interventions draws in complexities that don’t exist in a single risk factor conception of the world. What order should behaviours be tackled in? Or should they be tackled simultaneously? Which behaviours should take prominence? Services are having to design their approaches to multiple risk factors with very little academic research evidence addressing these questions.

Therefore, services like those in our report should be seen as generating vital evidence generation as they get the opportunity to contribute to these knowledge gaps. They shouldn’t be left alone to do this. The Department of Health and Social Care and Public Health England have a role to play in focusing research into multiple unhealthy risk factors. There is work to be done supporting local services to evaluate their impact on multiple risk factors and to facilitate the sharing of new knowledge generated from evaluation. Nationally, the Department and Public Health England also have the opportunity to consider how to break down some of the barriers to setting up these services by ensuring that broader policy does not focus solely on single behaviours. In our view, policy needs to catch up with the reality of people’s lives as they experience unhealthy risk factors, as our report shows practice is starting to do.

Given all we know about multiple unhealthy risk factors and the problems they present, we cannot continue in our siloed approach towards behaviour change. Our case studies, and services like them, are at the frontier of how we tackle multiple risk factors in the population, and it’s important to learn as much as we can from them to provide evidence and support for others developing services that tackle a public health issue that affects the majority of the public’s health.